© Borgis - Postępy Nauk Medycznych 8/2012, s. 644-650
*Witold Raciborski, Bartosz Pacewski, Andrzej Gabrusiewicz, Walerian Staszkiewicz
Wybór postępowania w tętniakach tętnic podkolanowych
The choice of management of popliteal artery aneurysms
Department of Vascular Surgery and Angiology of the Medical Centre for Postgraduate Education, The Jerzy Popiełuszko Memorial Bielański Hospital
Head of Department: prof. Walerian Staszkiewicz, MD, PhD
Tętniaki tętnic podkolanowych cały czas stanowią problem diagnostyczny i terapeutyczny. Autorzy przeanalizowali piśmiennictwo od 2000 roku oraz 24 przypadki leczonych w Klinice Chirurgii Naczyniowej i Angiologii CMKP, tętniaków tętnic podkolanowych. Rozpoznanie opiera się na wywiadzie, badaniu przedmiotowym i badaniu ultrasonograficznym. Badanie USG jest także przydatne w kwalifikacji do pilnej operacji i monitorowaniu powiększania się tętniaka. Badania arteriografii tomografii komputerowej i rezonansu magnetycznego stosowane są do wyboru optymalnego zabiegu planowego. Leczenie tętniaków (w zależności od rozmiarów i objawów) opiera się na klasycznej operacji lub leczeniu wewnątrznaczyniowym. Decyzja o rodzaju zabiegu powinna uwzględnić doświadczenie chirurga.
Podobne postępowanie diagnostyczno-terapeutyczne było stosowane w Klinice Chirurgii Naczyniowej i Angiologii CMKP. Wyniki leczenia tętniaków tętnicy podkolanowej są dość dobre. Rokowanie w leczeniu powikłanych tętniaków.
Popliteal artery aneurysms always constitute a diagnostic and a therapeutic problem. The authors have analysed the literature published since 2000 and 24 cases of popliteal artery aneurysms treated at the Department of Vascular Surgery and Angiology of the Medical Centre for Postgraduate Education. Diagnosis is based on medical history, physical examination and ultrasound evaluation. Ultrasound evaluation is also useful to qualify the patients for emergency surgery and for monitoring in order to observe a growing aneurysm. Computed tomography arteriography and magnetic resonance imaging are used for selection of an optimal method of an elective surgery. Treatment of aneurysms (depending on their size and symptoms) is based on a classic surgery orintravascular treatment. The decision of the type of treatment should dfinitely include the surgeon’s experience. A similar diagnostic and therapeutic procedure was used at the Department of Vascular Surgery and Angiology of the Medical Centre for Postgraduate Education. Treatment outcome in popliteal artery aneurysms is quite good. Prognosis in treatment of complicated popliteal artery aneurysms is uncertain.
Popliteal artery aneurysms constitute the largest group of aneurysms in vessels of the lower limbs. Dilation of the artery by 50% comparing to a diameter of the artery above and below the dilation is defined as aneurysms and due to possible occurrence of severe complications, it should not be underestimated (1, 2). In differential diagnosis, a popliteal cyst (Baker’s cyst) and dilation of the venous system within the peroneal vein should be mainly considered (3, 4).
Popliteal artery aneurysms may occur unilaterally and bilaterally and they may coexist with other aneurysms, e.g. aortic aneurysms, iliac aneurysms and femoral aneurysms (5). Sometimes, there are multiple aneurysms, which are the form of so-called elastopathy – dilations and expansions in many locations in the arteries. A cause of aneurysm formation has not been fully explained.
Aim of the study
Based on review of literature and own experience, the authors established a few goals regarding diagnosis and treatment of popliteal artery aneurysms:
1. Establishing suitability of the diagnostic methods in diagnosing and detecting popliteal artery aneurysms,
2. Selection of a surgical method: classical or endovascular,
3. Evaluation of outcome in the respective treatment methods.
Material, methods and result of a study
The articles published in Polish and foreign medical journals since 2000, dedicated to symptoms, diagnostics, diagnosis and treatment of popliteal artery aneurysms were analysed. The authors of this article also analysed 24 cases of popliteal artery aneurysms in 18 patients treated at the Department of Vascular Surgery and Angiology of the Medical Centre for Postgraduate Education. In 6 patients, popliteal artery aneurysms occurred bilaterally (33.3%).
Popliteal artery aneurysms may be asymptomatic, they may be detected by accident and they may manifest various symptoms (“symptomatic” aneurysms) (6).
The most common symptom of a chronic popliteal artery aneurysm established by the patient included growing tumour in the popliteal fossa, sometimes this tumour was pulsating in nature and accompanied by discomfort within the area of this limb. The second most common symptom in course of a popliteal artery aneurysm is intermittent claudication of varied intensity. Relatively common symptoms include peripheral oedema of the limb, digital cyanosis (“blue digit syndrome”), paresthesia and other disturbances of skin sensation, and a deep vein thrombosis of the shank. Persistent and intensive pain in the knee region occurs rarely. Severe and sudden pain may occur in case of the aneurysm rupture, which occurs rarely (a few percent) (7).
Ischemia of distal parts of the foot, digits, which may lead to necrosis, may be caused by embolization of a popliteal artery aneurysm (8). Symptoms of an acute ischemia of the lower limb (shank) result from thrombosis in the aneurysm, and they may characterise with quite peracute course (9).
Majority of the patients in the group treated at the Clinic revealed a pulsating tumour in the popliteal fossa (83.3%), exacerbation of intermittent claudication symptoms (66.7%), symptoms of an acute ischemia of the limb (33.3%) and a blue digit syndrome (27.8%).
Asymptomatic popliteal artery aneurysms are the most frequently established by accident, mainly during ultrasound screening evaluations or during evaluations of other structures of the knee. Also during an interview and a physical examination it is possible to obtain information suggesting possible presence of popliteal artery aneurysms. The interview provides us with data regarding occurrence of aforementioned symptoms. Many times during examination, the protrusion in the popliteal fossa is established, sometimes with noticeable pulsation in this area. In palpation, a pulsating, and practically painless tumour is established. It is also possible to evaluate progress of the potential ischemia of the limb, condition of the venous system, oedema and cyanosis of the digits (10). It encourages performing additional examinations, mainly ultrasound evaluation. In case of asymptomatic and symptomatic popliteal artery aneurysm, the ultrasound evaluation with colour imaging is the basic and generally available method of evaluation. Ultrasound evaluation is a quite precise method, especially if performed by an experienced physician, who knows the vascular pathology well. It is possible to evaluate size, shape and wall of the aneurysm, and to evaluate thickness and appearance of the thrombus inside of the aneurysm sac, blood flow in the aneurysm, as well as in the arteries above and below the aneurysm, and the ones branching off the aneurysm sac, and to evaluate lesions in the venous system (pressure on the veins caused by the aneurysm, and thrombotic lesions in the veins).
Newer and more precise studies to evaluate aneurysms include a computed tomography and a magnetic resonance with possible angiogram (CTA). These evaluations are helpful in planning surgical tactics, especially in case of endovascular treatment (11,12). However, these evaluations are less available and significantly more expensive that ultrasound evaluations.
Classical arteriography and subtraction arteriography are currently reserved to be performed during surgical procedure (13, 14).
In analyzed group of patients, who were hospitalized at Department of Vascular Surgery and Angiology, ultrasound evaluation was performed in all of them. Based on ultrasound evaluation, 12 aneurysms in 10 patients were qualified for treatment. These patients were at risk of loss of the limb due to thrombosis of the aneurysm and acute ischemia of the limb or exacerbation and critical ischemia of the limb. In other patients (12 aneurysms in 8 persons), an additional CTA evaluation was performed. These patients did not require an immediate treatment.
Therapeutic management in popliteal artery aneurysms depends on symptoms, which may occur within a course of a disease (15). If acute complications occur, such as acute ischemia of the lower limb, it is necessary to start treatment immediately (16). Acute ischemia in popliteal artery aneurysms is caused by thrombosis of the aneurysm or embolism of the shank arteries and rarely by its rupture (17, 18). It creates a risk of necrosis and loss of the limb.
In case of a thrombosis and an acute ischemia, if the patient is stable in terms of circulation and respiration, the treatment may start from an attempt to restore patency of the artery with thrombolytic treatment (19, 20). Such medicines as streptokinase, urokinase, tissue plasminogen activator or recombinant plasminogen activator administered intravenously by an infusion pump may be used generally or – which is recommended – locally, using an intra-arterial route through a special catheters. In case of intra-arterial local treatment, it is required to be able to place such catheter and it should be possible to monitor progress of therapy (ultrasound evaluation, control arteriograms). Such therapy should be conducted in specialist vascular centre. In such case, small doses of thrombolytic drug are administered (mainly recombinant plasminogen activator), which allow avoiding or reducing the number of possible complications of thrombolysis, especially bleeding. Restoring patency of the vessels with thrombolytic treatment may instantly protect the limb against amputation and by restoring microcirculation – improve prognosis after unavoidable surgical treatment. In case of no beneficial effect of the therapy, it is necessary to perform surgical treatment.
Thrombolytic treatment may also be used in embolized popliteal artery aneurysm and in the blue digit syndrome in patients, whose limb is not at direct risk of necrosis.
If we diagnose the aneurysm rupture, it is necessary to perform an emergency surgical treatment (18, 21, 22). In such cases, the classical surgery is performed, which includes ligation of the aneurysm and bypass graft or implantation of the graft into the aneurysm sac. Own vein of the patient, the most frequently the saphenous vein, or the vascular prosthesis made of artificial material are used as grafts (23). Recently, the articles have been published, which were dedicated to endovascular treatment of ruptured popliteal artery aneurysms, but the outcomes are not fully satisfying.
If the patient does not require an emergency surgery due to complicated aneurysm, tactics of therapeutic management may be considered and an optimum method of surgical treatment may be selected. Evaluation has to include size of an aneurysm and progression of the aneurysm grow, as well as atherosclerotic lesions accompanying the aneurysm, establishing which arteries are branching off within a changed wall of the aneurysm and what possible consequences may occur as a result of their “elimination” (24-27). The structures surrounding the aneurysm, especially including a venous and a muscular system, should also be evaluated. Mechanics of the knee joint is also important (12, 28, 29). After analysis of aforementioned factors, the patient is qualified for suitable surgical method of treatment. Selecting a type of classical surgery mainly depends on the operator’s experience (fig. 1). Advantage of a bypass graft surgery includes easier surgical approach, but bypass graft lengthens blood flow route and causes possibility of more frequent exposure to injuries and bending of the implant (the implant is placed under the skin at medial side of the knee). It is also necessary to ligate the aneurysm, i.e. to close its inflow and outflow, but the aneurysm stays in place. Advantage of implant placement into the aneurysm sac includes reconstruction of a “physiological” blood flow route and possibility of implantation of patent bypasses going from the aneurysm to the graft. The aneurysm is almost totally removed, as well as the thrombus inside. This type of surgery is burdened with higher number of complications, and surgical approach is difficult (30-35).
Fig. 1. Popliteal artery aneurysm.
Classical surgical treatment of popliteal artery aneurysms includes a radical treatment method, which permanently eliminates an aneurysm from circulation.
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Płatny dostęp do wszystkich zasobów Czytelni Medycznej
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